Vision
To help the United States achieve social arrangements that ensure that, when we must live with serious chronic illnesses associated with advancing age, we can count on living meaningfully and comfortably, at a sustainable cost to our families and society.

Why is Transforming Care of the Frail Elderly a Critical Systems Issue?
Our current health care system, developed to treat and cure acute illness and injury, is not prepared to care for the millions of people aging into the phase of life when they are likely to live for many years with chronic, eventually fatal, disabling conditions. Demographics and increased longevity have set up a perfect storm that now confronts America: burgeoning numbers of dependent elderly; diminishing numbers of increasingly unavailable family caregivers; and an increasingly dysfunctional care system that prioritizes short-term and costly medical interventions over continuity, comprehensiveness, and caregiver support. Fundamental transformation in how we care for one another is essential if we are to build a compassionate, effective, affordable, trustworthy system.

What Are Our Core Strategies for Addressing This Work?

• Conducting research that explores key issues and best practices in service delivery models, including costs and value and the preferences of groups and individuals who are living through the last phase of life;
• Using research findings to promote and inform public perspectives on specific, innovative approaches to improving systems and services and addressing cost;
• Designing and implementing demonstration projects in communities nationwide, with a particular focus on optimizing care transitions and continuity of care for the frail elderly who move within the care system; and
• Advocating in the policy arena to inform and guide leaders as they shape policies that will affect this time of life.

Where Will We Start?
The Center will focus its early work in two areas of critical importance: care transitions and caregiving. In both cases,
there is urgent need for research, demonstration, and advocacy efforts that can meaningfully shape the current environment while informing policy debate and facilitating widespread reform. Specifically, the Center will do the following:

• Support improving care of patients as they move among care settings (e.g., from hospital to home). Such care transitions are particularly difficult in current systems and lead to many errors. The federal government has announced a major national initiative to improve care transitions. The Center aims to help thousands of communities nationwide as they respond to this initiative and move to create seamless, comprehensive care.
• Build understanding of family and frontline caregiving and forge public commitment to improving social support for family caregivers. These caregivers have the potential to be a major force in creating reforms but must first recognize the political and social power that they wield.

Why Is Altarum Uniquely Positioned to Do This Work?
Altarum is a nonprofit research and consulting organization with decades of experience modeling, managing, and evaluating systems change in health care. Altarum has repeatedly demonstrated that it has the expertise, credibility, partnerships, and resources required to tackle difficult and at times divisive issues that affect human health.

How Will the Center’s Work Contribute to Broader Systems Change?
No research organization on its own will solve the crises awaiting us. However, the Center will catalyze several key improvements fundamental to progress in the quality, structure, delivery, and financing of care for this phase of life. In particular, the Center will

• Frame issues and choices in ways that are uncompromising, well researched, objective, and helpful to progress;
• Disseminate research findings—the Center’s and those of others—to engender creative conversation and lead to modeling and testing of alternative approaches;
• Build the public will for comprehensive and pragmatic solutions, making it appealing for political leaders to take on these topics in thoughtful and effective ways; and
• Develop and deploy an effective Internet information and referral service to support the significant scaleup needed in the care transitions arena, capitalizing on proven tools that will dramatically multiply the information resources available to clinicians and caregivers in communities nationwide.

Leadership
The Center is led by Dr. Joanne Lynn, a geriatrician, health services researcher, clinical improvement advisor, and policymaker with a distinguished history of service and a passion for finding practical ways to improve health and health care at a sustainable cost. Her broad array of methodological expertise means that the Center can bring to bear a wide array of drivers for substantial and sustained reform.

Products and Services
The Center produces products and services available to the general public, including the following:

• Handbook for Mortals: Guidance for People Facing Serious Illness. This book provides clear and compassionate guidance for patients and caregivers faced with a serious illness that will lead to death. Readers will find practical recommendations for the words that they can use and the actions that they can take to ensure comfort, meaning, and dignity for this phase of life. The book is made personal with the inclusion of photos, poems, and quotations that help humanize difficult issues.
• www.medicaring.org. This website provides practical and widely available resources to help make care transitions seamless and safe. The site also features the Care Transitions Search Widget, which prioritizes the most useful resources from the Web; a blog that provides timely and informative information and resources; and an introductory guide for those ready to lead care transitions reform in their own communities.
• Care Transitions Guide. This guide provides very specific information and links to help you find what works to fix care transitions, including how to fix the hospital discharge process and how to target rehospitalization. It provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Because care transitions have a major effect on very sick patients and their families, this guide also includes ideas for how coalitions can optimize use of palliative care programs and services.

Contact Information
To learn more about the ongoing work of the Center for Elder Care and Advanced Illness, please email eldercare@altarum.org or phone 202-776-5100. Additional information about the Center’s work in care transitions is also available at www.medicaring.org. For general information about Altarum, contact Jeff Moore at jeff.moore@altarum.org.